Environmental degradation, climate change and health from the perspective of Brazilian Indigenous stakeholders: a qualitative study.

BACKGROUND: The WHO identifies climate change as the most significant threat to global health systems. Indigenous peoples, whose lives are deeply intertwined with nature, are particularly vulnerable to the impacts of these changes. OBJECTIVE: This study aimed to understand the perspectives of Indigenous stakeholders and public services managers on the interconnectedness of climate change and Indigenous health. DESIGN: A qualitative study with 22 Indigenous stakeholders and public service managers on climate change and perceived impact on Indigenous health. SETTING AND PARTICIPANTS: Indigenous stakeholders and public service managers on climate change and perceived impact on Indigenous health from Brazil. Data was collected through interviews incorporating two vignette videos depicting environmental and health scenarios. Thematic content analysis was used to analyse the data. RESULTS: The analytical process yielded six subcategories that were further grouped into three overarching thematic macro-categories: environmental degradation and climate change in the context of Indigenous peoples; environment, vulnerability and impact on Indigenous mental health; and actions and public health policies for Indigenous peoples. CONCLUSION: The perspectives of Indigenous stakeholders and public service managers on the interconnectedness of climate change and Indigenous health were deeply entrenched in their lived experiences of loss of their lands from deforestation and environmental degradation. They argued strongly for the strengthening of public health policies aimed at the Indigenous peoples, to face many challenges, especially suicide, and to have a voice in decision-making. A sensitive approach that values Indigenous peoples' connections with nature is fundamental to promote their health and well-being.

Maternal and child health intervention to promote behaviour change: a population-level cluster-randomised controlled trial in Honduras.

OBJECTIVES: To assess the efficacy of a sustained educational intervention to affect diverse outcomes across the pregnancy and infancy timeline. SETTING: A multi-arm cluster-randomised controlled trial in 99 villages in Honduras' Copán region, involving 16 301 people in 5633 households from October 2015 to December 2019. PARTICIPANTS: Residents aged 12 and older were eligible. A photographic census involved 93% of the population, with 13 881 and 10 263 individuals completing baseline and endline surveys, respectively. INTERVENTION: 22-month household-based counselling intervention aiming to improve practices, knowledge and attitudes related to maternal, neonatal and child health. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes were prenatal/postnatal care behaviours, facility births, exclusive breast feeding, parental involvement, treatment of diarrhoea and respiratory illness, reproductive health, and gender/reproductive norms. Secondary outcomes were knowledge and attitudes related to the primary outcomes. RESULTS: Parents targeted for the intervention were 16.4% (95% CI 3.1%-29.8%, p=0.016) more likely to have their newborn's health checked in a health facility within 3 days of birth; 19.6% (95% CI 4.2%-35.1%, p=0.013) more likely to not wrap a fajero around the umbilical cord in the first week after birth; and 8.9% (95% CI 0.3%-17.5%, p=0.043) more likely to report that the mother breast fed immediately after birth. Changes in knowledge and attitudes related to these primary outcomes were also observed. We found no significant effect on various other practices. CONCLUSION: A sustained counselling intervention delivered in the home setting by community health workers can meaningfully change practices, knowledge and attitudes related to proper newborn care following birth, including professional care-seeking, umbilical cord care and breast feeding. TRIAL REGISTRATION NUMBER: NCT02694679.

Methodological guidelines and publications of benefit-risk assessment for health technology assessment: a scoping review.

OBJECTIVES: To map the available methodological guidelines and documents for conducting and reporting benefit-risk assessment (BRA) during health technologies' life cycle; and to identify methodological guidelines for BRA that could serve as the basis for the development of a BRA guideline for the context of health technology assessment (HTA) in Brazil. DESIGN: Scoping review. METHODS: Searches were conducted in three main sources up to March 2023: (1) electronic databases; (2) grey literature (48 HTA and regulatory organisations) and (3) manual search and contacting experts. We included methodological guidelines or publications presenting methods for conducting or reporting BRA of any type of health technologies in any context of the technology's life cycle. Selection process and data charting were conducted by independent reviewers. We provided a structured narrative synthesis of the findings. RESULTS: From the 83 eligible documents, six were produced in the HTA context, 30 in the regulatory and 35 involved guidance for BRA throughout the technology's life cycle. We identified 129 methodological approaches for BRA in the documents. The most commonly referred to descriptive frameworks were the Problem, Objectives, Alternatives, Consequences, Trade-offs, Uncertainty, Risk and Linked decisions and the Benefit-Risk Action Team. Multicriteria decision analysis was the most commonly cited quantitative framework. We also identified the most cited metric indices, estimation and utility survey techniques that could be used for BRA. CONCLUSIONS: Methods for BRA in HTA are less established. The findings of this review, however, will support and inform the elaboration of the Brazilian methodological guideline on BRA for HTA. TRIAL REGISTRATION NUMBER: https://doi.org/10.17605/OSF.IO/69T3V.

Wildfire, deforestation and health in tropical rainforest areas: a scoping review protocol.

INTRODUCTION: Wildfires and deforestation potentially have direct effects on multiple health outcomes as well as indirect consequences for climate change. Tropical rainforest areas are characterised by high rainfall, humidity and temperature, and they are predominantly found in low-income and middle-income countries. This study aims to synthesise the methods, data and health outcomes reported in scientific papers on wildfires and deforestation in these locations. METHODS AND ANALYSIS: We will carry out a scoping review according to the Joanna Briggs Institute's (JBI) manual for scoping reviews and the framework proposed by Arksey and O'Malley, and Levac et al. The search for articles was performed on 18 August 2023, in 16 electronic databases using Medical Subject Headings terms and adaptations for each database from database inception. The search for local studies will be complemented by the manual search in the list of references of the studies selected to compose this review. We screened studies written in English, French, Portuguese and Spanish. We included quantitative studies assessing any human disease outcome, hospitalisation and vital statistics in regions of tropical rainforest. We exclude qualitative studies and quantitative studies whose outcomes do not cover those of interest. The text screening was done by two independent reviewers. Subsequently, we will tabulate the data by the origin of the data source used, the methods and the main findings on health impacts of the extracted data. The results will provide descriptive statistics, along with visual representations in diagrams and tables, complemented by narrative summaries as detailed in the JBI guidelines. ETHICS AND DISSEMINATION: The study does not require an ethical review as it is meta-research and uses published, deidentified secondary data sources. The submission of results for publication in a peer-reviewed journal and presentation at scientific and policymakers' conferences is expected. STUDY REGISTRATION: Open Science Framework (https://osf.io/pnqc7/).

Methodological guidelines and publications of benefit-risk assessment for health technology assessment: a scoping review protocol.

BACKGROUND: Benefit-risk assessment (BRA) is used in multiple phases along the health technology's life-cycle to evaluate the balance between the benefits and risks, as it is fundamental to all stakeholders. BRA and its methodological approaches have been applied primarily in the context of regulatory agencies. However, BRA's application and extent in the context of health technology assessment (HTA) bodies remain less clear. Our goal is to perform a scoping review to identify and map methodological guidelines and publications on methods of BRA. This will be done considering the different phases of the life-cycle of health technologies to underline both the depth and extent of research concerning BRA, especially in the context of HTA. METHODS AND ANALYSIS: This scoping review protocol was developed following the framework proposed by Arksey and O'Malley, and the updated guidelines by the Joanna Briggs Institute. We will include methodological publications that provide recommendations or guidelines on methods for BRA. We will conduct electronic searches on Medline (PubMed) and EMBASE (Ovid) databases; manual searches on the main websites of HTA bodies and drug regulatory organisations; and contact experts in the field. Systematic extraction forms will be used to screen and assess the identified publications by independent assessors. We will provide a qualitative synthesis using descriptive statistics and visual tools. Results will be summarised in systematic evidence tables and comparative evidence scoping charts. ETHICS AND DISSEMINATION: This review will use data publicly available and does not require ethics approval. The results of this scoping review will contribute to scientific knowledge and act as a basis for methodologists, guideline developers and researchers for the development of BRA to inform regulatory decisions, reimbursement and coverage decision making. The results will be disseminated through peer-reviewed articles, conferences, policy briefs and workshops. TRIAL REGISTRATION NUMBER: Open Science Framework (https://doi.org/10.17605/OSF.IO/69T3V).

Who is most at risk of dying if infected with SARS-CoV-2? A mortality risk factor analysis using machine learning of patients with COVID-19 over time: a large population-based cohort study in Mexico.

OBJECTIVE: COVID-19 would kill fewer people if health programmes can predict who is at higher risk of mortality because resources can be targeted to protect those people from infection. We predict mortality in a very large population in Mexico with machine learning using demographic variables and pre-existing conditions. DESIGN: Cohort study. SETTING: March 2020 to November 2021 in Mexico, nationally represented. PARTICIPANTS: 1.4 million laboratory-confirmed patients with COVID-19 in Mexico at or over 20 years of age. PRIMARY AND SECONDARY OUTCOME MEASURES: Analysis is performed on data from March 2020 to November 2021 and over three phases: (1) from March to October in 2020, (2) from November 2020 to March 2021 and (3) from April to November 2021. We predict mortality using an ensemble machine learning method, super learner, and independently estimate the adjusted mortality relative risk of each pre-existing condition using targeted maximum likelihood estimation. RESULTS: Super learner fit has a high predictive performance (C-statistic: 0.907), where age is the most predictive factor for mortality. After adjusting for demographic factors, renal disease, hypertension, diabetes and obesity are the most impactful pre-existing conditions. Phase analysis shows that the adjusted mortality risk decreased over time while relative risk increased for each pre-existing condition. CONCLUSIONS: While age is the most important predictor of mortality, younger individuals with hypertension, diabetes and obesity are at comparable mortality risk as individuals who are 20 years older without any of the three conditions. Our model can be continuously updated to identify individuals who should most be protected against infection as the pandemic evolves.

Assessment of redundancy, methodological and reporting quality, and potential discrepancies of results of systematic reviews of early mobilisation of critically ill adults: a meta-research protocol.

INTRODUCTION: Several systematic reviews (SRs) have been conducted to determine the effectiveness of early mobilisation in critically ill adults with heterogeneous methodology and results. Redundancy in conducting SRs, unclear justification when leading new SRs or updating, and discordant results of SRs on the same research question may generate research waste that makes it difficult for clinicians to keep up to date with the best available evidence. This meta-research aims to assess the redundancy, methodological and reporting quality, and potential reasons for discordance in the results reported by SRs conducted to determine the effectiveness of early mobilisation in critically ill adult patients. METHODS AND ANALYSIS: A meta-research of early mobilisation SRs in critically ill adult patients will be conducted. A search of MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), Cochrane Library, Epistemonikos and other search resources will be conducted. Two independent reviewers will perform study selection, data extraction and quality appraisal. Discrepancies will be resolved by consensus or a third reviewer. The redundancy of SRs will be assessed by the degree of overlap of primary studies. In addition, the justification for conducting new SRs will be evaluated with the 'Evidence-Based Research' framework. The methodological quality of the SRs will be assessed with the A MeaSurement Tool to Assess systematic Reviews 2 tool, and the quality of the reports through compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. To assess the potential reasons for discordance in the results of the SRs considering divergence in results and their interpretation. ETHICS AND DISSEMINATION: As meta-research, this study does not involve the participation of people whose rights may be violated. However, this overview will be developed rigorously and systematically to achieve valid and reliable results. The findings of this meta-research study will be presented at conferences and published in a peer-reviewed journal related to rehabilitation, critical care or research methodology. TRIAL REGISTRATION NUMBER: osf.io/kxwq9.

Strategies used to manage overlap of primary study data by exercise-related overviews: protocol for a systematic methodological review.

INTRODUCTION: One of the most conflicting methodological issues when conducting an overview is the overlap of primary studies across systematic reviews (SRs). Overlap in the pooled effect estimates across SRs may lead to overly precise effect estimates in the overview. SRs that focus on exercise-related interventions are often included in overviews aimed at grouping and determining the effectiveness of various interventions for managing specific health conditions. The aim of this systematic methodological review is to describe the strategies used by authors of overviews focusing on exercise-related interventions to manage the overlap of primary studies. METHODS AND ANALYSIS: A comprehensive search strategy has been developed for different databases and their platforms. The databases to be consulted will be MEDLINE (Ovid), Embase (Ovid), The Cochrane Database of Systematic Reviews (Cochrane Library) and Epistemonikos. Two reviewers will independently screen the records identified through the search strategy and extract the information from the included overviews. The frequency and the type of overlap management strategies of the primary studies included in the SRs will be considered as the main outcome. In addition, the recognition of the lack of use of any overlap management strategy and the congruence between planning and conducting the overview focusing on overlap management strategies will be assessed. A subgroup analysis will be carried out according to the journal impact factor, year of publication and compliance with the Preferred Reporting Items for Overviews of Reviews statement. ETHICS AND DISSEMINATION: This study will not involve human subjects and therefore does not require ethics committee approval. However, the conduct and reporting of the findings of this review will be conducted in a rigorous, systematic and transparent manner, which relates to research ethics.The findings of this review will be presented at scientific conferences and published as one or more studies in peer-review scientific journals related to rehabilitation or research methods.

Inequity and vulnerability in Latin American Indigenous and non-Indigenous populations with rheumatic diseases: a syndemic approach.

Syndemics are a framework that documents health inequities and vulnerabilities in populations with rheumatic diseases. Compared with other approaches, syndemics are able to conjunctly consider epidemiological, biological, sociodemographic and economic factors, and their interactions. OBJECTIVE: To estimate health inequity and vulnerability among Indigenous and non-Indigenous populations with rheumatic and musculoskeletal diseases (RMD) in Latin America using the syndemic approach. DESIGN: This is a secondary analysis of a previously published large-scale study on the prevalence of RMD. SETTING: Studies carried out in five Latin American countries (Argentina, Colombia, Ecuador, Mexico and Venezuela). Health inequity and vulnerability in RMD were identified through a syndemic approach using network and cluster analysis. PARTICIPANTS: A total of 44 560 individuals were studied: 29.78% self-identified as Indigenous, 60.92% were female, the mean age was 43.25 years. Twenty clusters were identified in the Indigenous population and 17 in the non-Indigenous population. RESULTS: The variables associated with RMD among Indigenous populations were rurality, public health system, high joint biomechanical stress, greater pain, disability and alcoholism; and among non-Indigenous people they were being a woman, urban origin, older age, private health system, joint biomechanical stress, greater pain and disability. We identified different health inequities among patients with RMD (ie, lower educational attainment, more comorbidities), associated with factors such as Indigenous self-identification and rural residence. CONCLUSIONS: A syndemic approach enables us to identify health inequities in RMD, as shown by higher prevalence of comorbidities, disability and socioeconomic factors like lower educational attainment. These inequities exist for the overall population of patients with RMD, although it is more evident in Indigenous groups with added layers of vulnerability.

Mapping Chilean clinical research: a protocol for a scoping review and multiple evidence gap maps.

INTRODUCTION: Clinical research broadly aims to influence decision-making in order to promote appropriate healthcare. Funding agencies should prioritise research projects according to needed research topics, methodological and cost-effectiveness considerations, and expected social value. In Chile, there is no local diagnosis regarding recent clinical research that might inform prioritisation for future research funding. This research aims to comprehensively identify and classify Chilean health research studies, elaborating evidence gap maps for the most burdensome local conditions. METHODS AND ANALYSIS: We will search in electronic databases (MEDLINE, Embase, PsycINFO, CINAHL, LILACS and WoS) and perform hand searches to retrieve, identify and classify health research studies conducted in Chile or by authors whose affiliations are based in Chile, from 2000 onwards. We will elaborate evidence matrices for the 20 conditions with the highest burden in Chile (according to the Global Burden of Disease 2019) selected from those defined under the General Regime of the Health Guarantees Act. To elaborate the evidence gap maps, we will consider prioritised interventions and core outcome sets. To identify knowledge gaps and estimate redundant research, we will contrast these gap maps with the available international evidence of high or moderate certainty of evidence, for each specific clinical question. For this purpose, we will search systematic reviews using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. ETHICS AND DISSEMINATION: No ethical approval is required to conduct this project. We will submit our results in both peer-reviewed journals and scientific conferences. We will aim to disseminate our findings through different academic platforms, social media, local press, among others. The final results will be communicated to local funding agencies and government stakeholders. DISCUSSION: We aim to provide an accurate and up-to-date picture of the research gaps-to be filled by new future findings-and the identification of redundant research, which will constitute relevant information for local decision-makers.

Spin in the neurosurgical trauma literature: prevalence and associated factors - a systematic review protocol.

INTRODUCTION: Spin is defined as an inaccurate interpretation of results, intentionally or not, leading to equivocal conclusions and misdirecting readers to look at the data in an overly optimistic way. Previous studies have shown a high prevalence of spin in scientific papers and this systematic review aims to investigate the nature and prevalence of spin in the neurosurgical trauma literature. Any associated factors will be identified to guide future research practice recommendations. METHODS AND ANALYSIS: The Preferred Reporting Item for Systematic Reviews and Meta-Analyses recommendations will be followed. Randomised clinical trials (RCTs) that enrolled only patients with traumatic brain injury and investigated any type of intervention (surgical or non-surgical) will be eligible for inclusion. The MEDLINE/PubMed database will be searched for articles in English published in 15 top-ranked journals. Spin will be defined as (1) a focus on statistically significant results not based on the primary outcome; (2) interpreting statistically non-significant results for a superiority analysis of the primary outcome; (3) claiming or emphasising the beneficial effect of the treatment despite statistically non-significant results; (4) conclusion focused in the per-protocol or as-treated analysis instead of the intention-to-treat results; (5) incorrect statistical analysis; (6) republication of a significant secondary analysis without proper acknowledgement of the primary outcome analysis result. Traditional descriptive statistics will be used to present RCT characteristics. Standardised differences between the groups with or without spin will be calculated. The variables with a standardised difference equal or above 0.2 and 0.5 will be considered weakly and strongly associated with spin, respectively. ETHICS AND DISSEMINATION: This study will not involve primary data collection and patients will not be involved. TRIAL REGISTRATION NUMBER: 10.17605/OSF.IO/H3FGY.

Trajectories of success and/or distress: protocol for an observational cohort study investigating changing psychological distress among emerging Ecuadorian adults over a year.

INTRODUCTION: Emerging adulthood is a period of instability with changes in personal relationships and often a series of job changes before life trajectories clarify and more lasting decisions are possible. These changes often produce distress, and they might explain why most of the symptoms that impact the individual's mental health throughout their lives appear at this stage, although full-blown disorders are often only diagnosed subsequently. The objective of this study is to analyse the intraindividual changes in psychological distress and health-related quality of life in both student and non-student emerging adults over 1 year. Between-individual differences in variability will be analysed and life events will be recorded to identify possible associations. METHODS AND ANALYSIS: Participants will be emerging adults (18-29 years of age) students and non-students. The primary outcome will be psychological distress measured using the Clinical Outcomes in Routine Evaluation-Outcome Measure and the secondary outcome will be health-related quality of life measured by the EuroQol five-dimension-three-level. Sociodemographic and life events will be recorded. Information will be collected using an online survey.Analyses, described in a data analysis plan with the registration, will check the psychometric properties of the measures, describe the distribution of scores on the outcome measures, their relationship to group and other demographic variables and how they change over the seven assessment points across a year and explore any relationship between scores and life events. ETHICS AND DISSEMINATION: This study received ethical approval by the Comité de Ética y Bioética (Ethics and Bioethics Committee) of the Universidad de Las Américas, Quito-Ecuador (2020-0807). Results will be published in peer-reviewed journals and presented at relevant meetings. Brief reports of these publications will be disseminated using social media to reach the community and private or public organisations interested in emerging adults. TRIAL REGISTRATION NUMBER: NCT04596345.

Maternal health and Indigenous traditional midwives in southern Mexico: contextualisation of a scoping review.

OBJECTIVES: Collate published evidence of factors that affect maternal health in Indigenous communities and contextualise the findings with stakeholder perspectives in the Mexican State of Guerrero. DESIGN: Scoping review and stakeholder fuzzy cognitive mapping. INCLUSION AND EXCLUSION: The scoping review included empirical studies (quantitative, qualitative or mixed methods) that addressed maternal health issues among Indigenous communities in the Americas and reported on the role or influence of traditional midwives before June 2020. The contextualisation drew on two previous studies of traditional midwife and researcher perspectives in southern Mexico. RESULTS: The initial search identified 4461 references. Of 87 selected studies, 63 came from Guatemala and Mexico. Three small randomised trials involved traditional midwives. One addressed the practice of traditional midwifery. With diverse approaches to cultural differences, the studies used contrasting definitions of traditional midwives. A fuzzy cognitive map graphically summarised the influences identified in the scoping review. When we compared the literature's map with those from 29 traditional midwives in Guerrero and eight international researchers, the three sources coincided in the importance of self-care practices, rituals and traditional midwifery. The primary concern reflected in the scoping review was access to Western healthcare, followed by maternal health outcomes. For traditional midwives, the availability of hospital or health centre in the community was less relevant and had negative effects on other protective influences, while researchers conditioned its importance to its levels of cultural safety. Traditional midwives highlighted the role of violence against women, male involvement and traditional diseases. CONCLUSIONS: The literature and stakeholder maps showed maternal health resulting from complex interacting factors in which promotion of cultural practices was compatible with a protective effect on Indigenous maternal health. Future research challenges include traditional concepts of diseases and the impact on maternal health of gender norms, self-care practices and authentic traditional midwifery.

Lag times in the publication of network meta-analyses: a survey.

OBJECTIVE: We assessed the extent of lag times in the publication and indexing of network meta-analyses (NMAs). STUDY DESIGN: This was a survey of published NMAs on drug interventions. SETTING: NMAs indexed in PubMed (searches updated in May 2020). PRIMARY AND SECONDARY OUTCOME MEASURES: Lag times were measured as the time between the last systematic search and the article submission, acceptance, online publication, indexing and Medical Subject Headings (MeSH) allocation dates. Time-to-event analyses were performed considering independent variables (geographical origin, Journal Impact Factor, Scopus CiteScore, open access status) (SPSS V.24, R/RStudio). RESULTS: We included 1245 NMAs. The median time from last search to article submission was 6.8 months (204 days (IQR 95-381)), and to publication was 11.6 months. Only 5% of authors updated their search after first submission. There is a very slightly decreasing historical trend of acceptance (rho=-0.087; p=0.010), online publication (rho=-0.080; p=0.008) and indexing (rho=-0.080; p=0.007) lag times. Journal Impact Factor influenced the MeSH allocation process, but not the other lag times. The comparison between open access versus subscription journals confirmed meaningless differences in acceptance, online publication and indexing lag times. CONCLUSION: Efforts by authors to update their search before submission are needed to reduce evidence production time. Peer reviewers and editors should ensure authors' compliance with NMA standards. The accuracy of these findings depends on the accuracy of the metadata used; as we evaluated only NMA on drug interventions, results may not be generalisable to all types of studies.

Involvement of people who inject drugs in injection initiation events: a cross-sectional analysis identifying similarities and differences across three North American settings.

OBJECTIVES: People who inject drugs (PWID) play an integral role in facilitating the entry of others into injection drug use (IDU). We sought to assess factors influencing PWID in providing IDU initiation assistance across three distinct North American settings and to generate pooled measures of risk. DESIGN: We employed data from three PWID cohort studies participating in PReventing Injecting by Modifying Existing Responses (PRIMER), for this cross-sectional analysis. SETTING: Tijuana, Mexico; San Diego, USA; Vancouver, Canada. PARTICIPANTS: A total of 2944 participants were included in this study (Tijuana: n=766, San Diego: n=353, Vancouver: n=1825). MEASUREMENTS: The outcome was defined as recently (ie, past 6 months) assisting in an IDU initiation event. Independent variables of interest were identified from previous PRIMER analyses. Site-specific multiple modified Poisson regressions were fit. Pooled relative risks (pRR) were calculated and heterogeneity across sites was assessed via linear random effects models. RESULTS: Evidence across all three sites indicated that having a history of providing IDU initiation assistance (pRR: 4.83, 95% CI: 3.49 to 6.66) and recently being stopped by law enforcement (pRR: 1.49, 95% CI: 1.07 to 2.07) were associated with a higher risk of providing assistance with IDU initiation; while recent opioid agonist treatment (OAT) enrolment (pRR: 0.64, 95% CI: 0.43 to 0.96) and no recent IDU (pRR: 0.21, 95% CI: 0.07 to 0.64) were associated with a lower risk. We identified substantial differences across site in the association of age (I2: 52%), recent housing insecurity (I2: 39%) and recent non-injection heroin use (I2: 78%). CONCLUSION: We identified common and site-specific factors related to PWID's risk of assisting in IDU initiation events. Individuals reporting a history of assisting IDU initiations, being recently stopped by law enforcement, and recently injecting methamphetamine/speedball were more likely to have recently assisted an IDU initiation. Whereas those who reported not recently engaging in IDU and those recently enrolled in OAT were less likely to have done so. Interventions and harm reduction strategies aimed at reducing the harms of IDU should incorporate context-specific approaches to reduce the initiation of IDU.

Cross-sectional study to measure household water insecurity and its health outcomes in urban Mexico.

OBJECTIVE: To assess the links between structural and household determinants of household water insecurity and test three water insecurity measures against self-reported diarrhoea, dengue fever and perceived stress in the middle-income and low-income urban areas of Torreón, Mexico. DESIGN: Cross-sectional household survey conducted in two waves (rainy and dry seasons). PARTICIPANTS: 500 households selected via multistage cluster sample in selected communities. Socioeconomic status determined the selection of participant neighbourhoods; five were identified in low socioeconomic status neighbourhoods and five in low-medium socioeconomic status neighbourhoods. We examine how the context of urban water provision is related to a new cross-culturally valid Household Water Insecurity Experiences (HWISE) Scale. PRIMARY OUTCOME MEASURES: The HWISE Scale, self-reported diarrhoea, dengue fever and the Perceived Stress Scale. RESULTS: Water system intermittency (adjusted OR (AOR) 3.96, 95% CI 2.40 to 6.54, p<0.001), unpredictability (AOR 2.24, 95% CI 1.34 to 3.74, p=0.002) and the dry season (AOR 3.47, 95% CI 2.18 to 5.52, p<0.001) were structural correlates of the HWISE Scale. This study also found that the HWISE Scale was associated with two health outcomes, self-reported diarrhoea (AOR 1.09, 95% CI 1.03 to 1.15, p=0.002) and perceived stress (ß=0.28, SE=0.07, t=4.30, p<0.001), but not self-reported dengue fever (AOR 1.02, 95% CI 0.98 to 1.06). A 3-item hygiene subscore and a 3-item water worry subscore were also both positively associated with self-reported diarrhoea and perceived stress. CONCLUSION: Short-form screeners of water insecurity may be useful for assessing certain health risks by lay survey workers in settings with limited healthcare resources, particularly in lieu of more expensive microbiological tests that require specialised training and facilities.

Beyond deaths per capita: comparative COVID-19 mortality indicators.

OBJECTIVES: Following well-established practices in demography, this article discusses several measures based on the number of COVID-19 deaths to facilitate comparisons over time and across populations. SETTINGS: National populations in 186 United Nations countries and territories and populations in first-level subnational administrative entities in Brazil, China, Italy, Mexico, Peru, Spain and the USA. PARTICIPANTS: None (death statistics only). PRIMARY AND SECONDARY OUTCOME MEASURES: An unstandardised occurrence/exposure rate comparable to the Crude Death Rate; an indirectly age-and-sex standardised rate that can be derived even when the breakdown of COVID-19 deaths by age and sex required for direct standardisation is unavailable; the reduction in life expectancy at birth corresponding to the 2020 number of COVID-19 deaths. RESULTS: To date, the highest unstandardised rate has been in New York, at its peak exceeding the state 2017 crude death rate. Populations compare differently after standardisation: while parts of Italy, Spain and the USA have the highest unstandardised rates, parts of Mexico and Peru have the highest standardised rates. For several populations with the necessary data by age and sex for direct standardisation, we show that direct and indirect standardisation yield similar results. US life expectancy is estimated to have declined this year by more than a year (-1.26 years), far more than during the worst year of the HIV epidemic, or the worst 3 years of the opioid crisis, and to reach its lowest level since 2008. Substantially larger reductions, exceeding 2 years, are estimated for Panama, Peru, and parts of Italy, Spain, the USA and especially, Mexico. CONCLUSIONS: With lesser demand on data than direct standardisation, indirect standardisation is a valid alternative to adjust international comparisons for differences in population distribution by sex and age-groups. A number of populations have experienced reductions in 2020 life expectancies that are substantial by recent historical standards.

International Physical Activity and Built Environment Study of adolescents: IPEN Adolescent design, protocol and measures.

INTRODUCTION: Only international studies can provide the full variability of built environments and accurately estimate effect sizes of relations between contrasting environments and health-related outcomes. The aims of the International Physical Activity and Environment Study of Adolescents (IPEN Adolescent) are to estimate the strength, shape and generalisability of associations of the community environment (geographic information systems (GIS)-based and self-reported) with physical activity and sedentary behaviour (accelerometer-measured and self-reported) and weight status (normal/overweight/obese). METHODS AND ANALYSIS: The IPEN Adolescent observational, cross-sectional, multicountry study involves recruiting adolescent participants (ages 11-19 years) and one parent/guardian from neighbourhoods selected to ensure wide variations in walkability and socioeconomic status using common protocols and measures. Fifteen geographically, economically and culturally diverse countries, from six continents, participated: Australia, Bangladesh, Belgium, Brazil, Czech Republic, Denmark, Hong Kong SAR, India, Israel, Malaysia, New Zealand, Nigeria, Portugal, Spain and USA. Countries provided survey and accelerometer data (15 countries), GIS data (11), global positioning system data (10), and pedestrian environment audit data (8). A sample of n=6950 (52.6% female; mean age=14.5, SD=1.7) adolescents provided survey data, n=4852 had 4 or more 8+ hours valid days of accelerometer data, and n=5473 had GIS measures. Physical activity and sedentary behaviour were measured by waist-worn ActiGraph accelerometers and self-reports, and body mass index was used to categorise weight status. ETHICS AND DISSEMINATION: Ethical approval was received from each study site's Institutional Review Board for their in-country studies. Informed assent by adolescents and consent by parents was obtained for all participants. No personally identifiable information was transferred to the IPEN coordinating centre for pooled datasets. Results will be communicated through standard scientific channels and findings used to advance the science of environmental correlates of physical activity, sedentary behaviour and weight status, with the ultimate goal to stimulate and guide actions to create more activity-supportive environments internationally.

Use of infectious disease surveillance reports to monitor the Zika virus epidemic in Latin America and the Caribbean from 2015 to 2017: strengths and deficiencies.

OBJECTIVES: To summarise the occurrence of congenital Zika syndrome (CZS) in Latin America and the Caribbean from 2015 to 2017 using two outcome measures derived from infectious disease surveillance reports and to assess the completeness of these reports. DESIGN: Surveillance study. SETTING: Pan American Health Organization (PAHO)/WHO epidemiology reports on confirmed and suspected Zika virus infection and cases of CZS. PARTICIPANTS: Populations of 47 countries in the South and Central Americas, Mexico and the Caribbean. PRIMARY AND SECONDARY OUTCOME MEASURES: The number of CZS cases per 1000 births (using 2016-2017 births as a denominator) and the number of CZS cases per 1000 births in women with Zika virus infection during pregnancy. RESULTS: By 4 January 2018, 548623 suspected and 239063 confirmed Zika virus infections had been reported to PAHO/WHO from 47 countries. In 25 countries, over 80% of infections were reported as suspected. There were 3617 confirmed CZS cases in 25 countries; 2952 (82%) had occurred in Brazil. The number of CZS cases per 1000 births varied considerably with Brazil and several Caribbean island communities (Puerto Rico, St Martin, Martinique, Guadeloupe and Grenada) having the highest CZS prevalence above 0.5 per 1000 births. Analysing the number of CZS cases per 1000 births in women infected with Zika virus during their pregnancy highlighted the inaccuracies of the data, with Venezuela likely to have had severe under-reporting of CZS. CONCLUSIONS: Expressing data on CZS in relation to total births, rather than as absolute numbers, better illustrates the burden of disease, providing that under-reporting of CZS is not too severe. Data on infections in pregnant women enable potential under-reporting of CZS to be identified. Both measures are recommended for future PAHO/WHO publications. Evidence of severe under-reporting of Zika virus infections and CZS makes interpretation of the data and comparisons between countries challenging.

Spatial inequalities of major lower limb amputation rates in Paraná state, Brazil.

OBJECTIVE: The aim of this observational cross-sectional study was to analyse the spatial distribution of major lower limb amputation (MLLA) rates and associate them to socioeconomic, demographic and public healthcare access-related variables in the State of Paraná, Brazil, from 2012 to 2017. METHOD: Data on MLLA, revascularisation surgeries, diagnostic exams and healthcare coverage were obtained from the Brazilian Public Hospital Information System. Socioeconomic data were obtained from the Brazilian Institute of Geography and Statistics. Spatial autocorrelation of the MLLA rates was tested using Moran's I method. Multivariate spatial regression models using ordinary least squares regression (OLS) and geographically weighted regression (GWR) were used to identify the variables significantly correlated with MLLA. RESULTS: A total of 5270 MLLA were included in the analysis. Mean MLLA rates were 24.32 (±18.22)/100 000 inhabitants, showing a positive global spatial autocorrelation (Moran's I=0.66; p<0.001). Queen contiguity matrix demonstrates that MLLA rates ranged from 7.6 to 46.6/100 000 with five large clusters of high MLLA rates. OLS showed that four of the nine studied variables presented significant spatial correlation with MLLA rates. Colour Doppler ultrasound showed a negative association (p<0.001), while revascularisation surgeries and illiteracy showed a positive correlation (p<0.01). GWR presented the best model (adjusted R2=0.77) showing that the predictors differentially affect the MLLA rates geographically. CONCLUSION: The high MLLA rates in some regions of the state are influenced by the high rate of illiteracy and low utilisation rate of colour Doppler, indicating a social problem and difficulty in accessing health. On the other hand, the high rates of revascularisation surgeries are related to higher MLLA rates, possibly due to delayed access to specialised hospitals. This indicates that attention must be given to population access to public healthcare in the State of Paraná in order to ensure proper and timely medical attention.